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Treating an anatomic problem vs. providing an improved functional outcome
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A patient presented to me recently with a history of cataract surgery in the left eye done a year ago.
He had a wide superior scleral tunnel incision and what appeared to be an anterior chamber IOL with the part of the haptics above the iris at the angle and the rest of the IOL in the sulcus. The anterior segment was quiet and without inflammation, and the patient's only complaint was the poor vision, which was 20/800 (Figure 1).
Figure 1. Dislocated IOL.
On further examination, it turns out that the patient has an APD in this eye and fundus examination shows a pale optic nerve, atrophic vasculature, an ischemic macula and proliferative diabetic retinopathy with prior laser photocoagulation (Figure 2).
Figure 2. Retina.
While I would enjoy the challenge of doing an IOL exchange or IOL repositioning for this patient, I don't think it would provide an improvement in his vision.
Yes, we could certainly fix the anatomic problem of the dislocated IOL, but with such a damaged posterior segment, further visual recovery would be unlikely.
In the future, if the IOL causes other issues such as iris damage, chronic inflammation or glaucoma, we can certainly address it at that time. But for now, the best surgery for him is no surgery at all.
Fortunately, his other eye had a well-positioned posterior chamber IOL and a healthier retina with 20/50 vision. He will be followed closely by a retinal specialist as well.